Veterans_Morrison' �F�rm Number 12A - Revised 1985
�f °Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Application for Deduction From the
� AssessedQValuation of Taxable Propert������
**•^ ualifications On BacY. '**
STATE OF INDIANA �(�J� COUNTY, S�PR 10 1991 �
(Name) (-�j_�e ��)��/ , being d swor o h ays
�hat (s)he is years of age; that (s)he resi �{g�$QN OU TYAUDI70R
in County, Indiana; that (s)he
Check One: w s a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S. Armed Forces
who served during any of its wars
and who has been honorably discharged therefrom and 'nas a service-
connected disability of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
Pension Certificate or
Award of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the�
.. Department of the Defense Disability Retirement Board of the
: appropriate branch of the armed forces
exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $��
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
That, in .addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
� ��
(Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this _
day of . 19_ '
Auditor